Healthcare Provider Details

I. General information

NPI: 1215051305
Provider Name (Legal Business Name): SCCA-ORAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 EASTLAKE AVE E SUITE G6900
SEATTLE WA
98109-4405
US

IV. Provider business mailing address

PO BOX 357131
SEATTLE WA
98195-7131
US

V. Phone/Fax

Practice location:
  • Phone: 206-288-1333
  • Fax: 206-288-1332
Mailing address:
  • Phone: 206-616-8794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. EDMOND L. TRUELOVE
Title or Position: CHAIR & PROFESSOR
Credential: DDS, MSD
Phone: 206-616-8794